Challenges to Substance Abuse and HIV Prevention In Los Angeles County

1. Challenges to Substance Abuse and HIV Prevention In Los Angeles County Rosemary C. Veniegas, Ph.D. Associate Director, Intervention Core UCLA Center for HIV Identification, Prevention and Treatment Services

2. National Context • Infectious Diseases • CDC – DEBIs (Diffusion of Effective Behavioral Interventions) • Substance Abuse, Mental Health • NIDA – Clinical Trials Networks (CTN) • SAMHSA – NREPP (National Registry of Evidence-based Programs and Practices) • Health Care/Services • AHRQ – PPIP (Put Prevention Into Practice)

3. CDC DEBI Websitewww.effectiveinterventions.org • SAMHSA NREPP website

4. Los Angeles Context • Infectious Diseases • 2004-2008 HIV Prevention Plan • Healthy Relationships, Mpowerment, Many Men, Many Voices, Popular Opinion Leader, Community PROMISE, RAPP, Safety Counts, SISTA, Real AIDS Prevention Project, Turning Point, VOICES/VOCES • Substance Abuse, Mental Health • Clinical Trials Network • Los Angeles County Evaluation System (LACES) • SAMHSA awards pending

5. Compliance Contexts • HIV/AIDS • Prevention program performance indicators • Standards of care • Substance Abuse • NIDA Principles • Practice Guidelines (e.g., 5 A’s) • Research to Practice • Evidence-based medicine • Single drug vs. multi-drug tx regimens

6. Evidence-Based Interventions • Adherence • Essential and non-essential elements • Dose • Completeness of delivery • Quality of delivery • Facilitator skills • Participant responsiveness • Client satisfaction/centeredeness

7. Countywide Evaluation Capacity Needs Assessment • What level of capacity? • Array of medical and non-medical prevention services • Telephone survey, Jul-Aug 2005 • Funded by OAPP contract H700024 • S Lee, P Batterham, U Kao, C Hucks-Ortiz, G Victorianne, S Shoptaw, M Etzel • 69 providers (Health Education/Risk Reduction, Prevention Case Management, School-based) • Excluded HIV Counseling and Testing programs • 91% response rate

8. Evaluation Capacity Questions • Program evaluation • Formative, process, outcome monitoring, impact • Can CBO’s implement evidence-based interventions? • In what areas will they need further assistance? • What are the implications for evidence-based practices?

9. Respondents

10. Respondents

11. What types of trainings have you completed?

12. Evaluation Experience 2.11 2.17 2.25 2.13 2.38 2.16 2.30 2.15 2.26 2.11 2.52 2.40 Scale: 0=No experience, 1=Some experience, 2=Moderate experience, 3=Extensive experience

13. Evaluation Responsibilities

14. Evaluation Activities Performed

15. Methods of Evaluation

16. Evaluation Protocols and Procedures

17. Evaluation Capacity Summary • Publicly funded CBOs • Are familiar with evidence-based concepts (e.g., behavioral theories, group facilitation) • Use multiple data gathering methods • Have access to database management tools • Have conducted formative and process evaluation • Infrastructure for implementing evidence-based interventions?

18. Challenges • Publicly funded CBOs • Multiple regulatory and funding compliance issues • Low, medium and high capacity • LACES project challenges (Rawson et al.) • 14 hours of training to do ASI • One-third of providers with no or dated computers • Buy-in of decisionmakers

19. Challenges • Publicly funded CBOs • Continuing need for “program evaluation training” “…how to use Microsoft Access; how to enter data so that they can be linked together e.g. individual-level counseling data to be linked to outreach data; how to measure the indicators that they are required to report on.” “Have trainings on evaluation and follow-up with one-on-one technical assistance. Topics include on how to design an evaluation and how to develop data collection tools to gather information on their program.”

20. HIV Technology Transfer in Los Angeles • How are evidenced-based interventions being used in Los Angeles County? • Funded by UARP IDEA award ID05-LA024 • Collaboration with City of LA AIDS Coordinator’s Office • R Rosales, U Kao • Key informant interviews • Wave 1 Dec 2005-May 2006, N =34 • Wave 2 Aug 2006-Oct 2006

21. Aims • To identify specific strategies used to ensure success/overcome barriers during each of the TTM phases • To identify specific technology transfer training and technical assistance resources that are needed by Los Angeles CBOs during each TTM phase.

22. Technology Transfer Model (Kraft et al., 2000) Pre-implementation Implementation Maintenance & Evolution • Review prevention needs • Acquire information • Assess fit • Prepare organization/staff • Secure technical assistance • Conduct process evaluation • Support staff • Support organization change and institutionalization • Conduct process, outcome, and cost evaluations

23. Model Developed for CDC DEBIs

24. What are Core Elements? • Critical elements believed to be responsible for its effectiveness • Program components that leads to behavior change (e.g. types of skills-building, qualifications of staff, consistent delivery) • Elimination or modifications of these elements may not lead to expected outcomes. (CDC, 2003)

25. What are Core Elements? • “Required elements that represent the theory and internal logic of the intervention and most likely produce the intervention’s main effects • Researchers identify core elements through research and practice • Core elements must be implemented with fidelity to increase the likelihood that prevention providers will have program outcomes that are similar to those in the original research.”(CDC, 2005)

26. Examples of Interventions in LA • Street Smart for Latino YMSM • Added core elements • Safety Counts in an abstinence-based setting • Fit with core elements • Mpowerment and SISTA for transgenders • Changed target population • VOICES/VOCES for MSM • Changed target population

27. What are Key Characteristics? • Crucial activities and delivery methods for conducting an intervention • Example: For a group-level intervention do your staff have group facilitation skills? • CAN be adapted to meet the needs of target population and ensure cultural appropriateness (CDC Procedural Guidance, 2003)

28. INTERNAL LOGIC MODEL SAFETY COUNTS INTERVENTION ACTIVITIES (Core Elements) INDIVIDUAL DETERMINANTS OF RISK BEHAVIOR (Immediate Outcomes) INTENDED OUTCOMES (Intermediate & Long-term) GROUP SESSION ONE: Where do I stand with reducing my risks? PERCEIVED RISK, READINESS FOR CHANGE IDENTIFY PERSONAL RISK BEHAVIORS GROUP SESSION TWO: Developing risk-reduction goals. KNOWLEDGE, SKILLS SET PERSONAL RR GOAL INDIVIDUAL SESSION: Help client identify and overcome barriers SELF-EFFICACY STRENGTHEN INTENTION TO ACHIEVE RR GOAL SOCIAL EVENTS: Risk reduction activity. Receive reinforcement for personal risk reduction. SOCIAL SUPPORT MAKE PROGRESS TOWARD ACHIEVING RR GOAL (HIGHER STAGE OF CHANGE) REDUCE UNPROTECTED SEX AND/OR NEEDLE SHARING FOLLOW-UP CONTACTS: Verify and validate client’s goal progress. BELIEFS (PROS & CONS) Adapted from the CDC

29. Wave 1 Interview Results • Staff who are involved with EBIs at their agency • 18 agencies funded by LA County • 20 agencies funded by LA City • 41 staff contacted, 6 unable to contact • 3 staff declined • N = 34

30. Gender (N=34)

31. Race/Ethnicity (N=43)

32. How long have you worked in the field of HIV prevention?

33. How long have you been employed with your agency?

34. How many Mean • HIV prevention programs are currently being conducted by your agency? 4.5 • evidence-based HIV prevention interventions are currently being conducted by your agency? 3.1 • evidence-based HIV preventions interventions have you worked on since you began working at this agency? 3.2

35. How long have key staff…working on EBIs, been in their positions at your agency?

36. In what intervention-related areas have you received training? • HCT 50% • Substance abuse prevx 44% • Budget development 41% • Program coordination 38% • Statistics 26% • Other (grant writing, logic models, management social marketing) 12% • Behavioral theory 82% • Specific EBIs 79% • Group facilitation 71% • Health education 68% • Curr. Development 68% • Program evaluation 62% • Adaptation 53% • Qnre Development 50%

37. In what evidence-based intervention-related areas would you like to receive training? • Statistics 44% • Adaptation 44% • Curr. development 35% • Program evaluation 32% • Program coord. 26% • Budget Development 26% • Group facilitation 24% • Behavioral Theory 21% • Qnre development 21% • HCT 15% • Specific EBIs 12% • Health education 9% • Other (data mgmt, reaching IDUs, forms use) 6%

38. Technology Transfer Capacity Summary Publicly funded CBOs in Los Angeles • Have been trained in evidence-based interventions (EBIs) • Have used 1 or more EBIs • Are trained in behavioral theories and group facilitation skills • Fewer than half (44%) have been trained in substance abuse prevention

39. Pre-implementation Strategies • Responding to changes in funders’ priorities • One that it’s mandatory to use evidence-based interventions if we’re going to survive as a nonprofit. Two it’s mandated by CDC. And three is from funders and many researchers that a lot of this stuff works. MSM & MSMW program, 10+ yrs in HIV prevention • …we went to the Bidder’s conference. There were a lot of talks about DEBIs, the Diffusion of Effective Behavioral Interventions. So we kept hearing about DEBIs, DEBIs, DEBIs. And there was a strong push to do a DEBI. WSR program, 5-10 yrs in HIV prevention

40. Pre-implementation Strategies • Learning about EBIs • For me I got a lot of my information from my person that was in my position before. So he went to a lot of the trainings. I’ve kind of learned just by one, reading the actual document, two having conversation with our actual program, is it our Program Officer, from our funding source. But that’s where I’ve received most of the information from. MSM & MSMW program, 6-12 mos in HIV prevention • I heard of them prior to the CDC announcing the new HIV initiative because at that time we were funded by the CDC, and they were telling us that these the changes that are coming down the pipe. Then we applied for… we went to that training for 04064, I think, when we saw something about evidenced-based…That was my formal introduction to evidence-based. WSR program, 10+ yrs in HIV prevention

41. Pre-implementation Strategies • Preparing organization • We take our recommendations from the PPC [Prevention Planning Committee] …What, where the [agency] really need? We’re having those conversations right now actually. Where does the [agency] really need to start focusing? What’s the trend? What are people, where do we need to go? Because it’s all about pre-planning. It’s always like pre-production. It’s always where will we be in six months? What’s the focus going to be? MSM program, 3-5 yrs in HIV prevention • We decided that these interventions would meet the need…we looked at HIV incident data, we looked [at] prevalence…relating to HIV. And we talked to different community leaders and other collaborating agencies… And this was also based on our past HIV programs experience that we thought these interventions would be a good fit. We believe that we needed a group level intervention and we needed an individual level intervention. MSM program, 10+ yrs in HIV prevention

42. Pre-implementation Strategies • Adapting interventions • Like I grabbed an exercise from Session 8 and I put it in Session 6. I think Session 5 is a complete waste of time so I’m not doing it with this population. You know and I think Session 7 is not going to help [a client] so I’m not going to do that. Transgender program, 6-12 mos in HIV prevention • we took the training that was supposed to be across 5 days, and we began to, to conduct the training, first as a 4 day training, they usually actually did a pilot with it. And so conducted about 3 pilots. A 5 day training pilot, a 2 day weekend training pilot and a 3 day Monday through Wednesday pilot. So, after discussing the different pilots, we came to the conclusion that the best thing was a 3 day…workshop. MSM & MSMW program, 10+ yrs in HIV prevention

43. Implementation Strategies • Complying with funders’ requirements • Like for example, Mpowerment. They [funder] have requirements for what we have to do for Mpowerment. So like it’s training, we have to train up to 16 hours, staff members, certify them. Around the country, the same curriculum, people look at us like what? You have to make them go through a training? So basically, [the funder] has modified a lot of the curriculum…for contractual purposes… MSM & MSMW program, 5-10 yrs in HIV prevention • The way it’s translated by the [funder] is training that is supposed to take place over three sessions, which is completely opposite and is counter to what’s it’s supposed to be doing. MSM & MSMW program, 5-10 yrs in HIV prevention

44. Implementation Strategies • Ensuring relevance to clients • We look at the population. We look at all the issues in program implementations, the charts, how you gonna deliver it, whether it’s not feasible in an urban metro area, rural area, is that gonna be successful? WSR program, 10+ yrs in HIV prevention • And it wasn’t until we started finding groups that would primarily consist of only maybe monolingual clients, we realized everything had to be translated. And make sure that its appropriate in terms of like literacy levels and they were also getting the same point across so that was, that’s a challenge and I think we’re still in the process of trying to revise things to make sure that they’re that everything’s in Spanish. But I think the other main problem is that our clientele is, our BRG is MSM, MSMW, and that is a challenge in itself because the video is a heterosexual video. MSM & MSMW program, 6-12 mos in HIV prevention

45. Implementation Strategies • Standardized Forms • I mean, why reinvent the wheel if it’s already been invented? …I mean, like, we have to create all these forms. Why expect us to do it if we already have a sample (inaudible)? Or like, well you should… again, if we would have had those things already in place, we could have started the program… we could have started earlier. MSM& MSMW program, 6-12 mos in HIV prevention • My agency was able to standardized the forms, so we use the same forms as in [EBI] as use for [another EBI]. That way it is across the board. So of course, we have to send them to the trainings outside the agency but in internally it is an ongoing training process for them to really ensure that they know how to fill out the forms, how to fill out the commitment, how to fill out the follow-up. Various BRGs program, 5-10 yrs in HIV prevention

46. Implementation Strategies • Recruitment and retention • …yeah, I think recruitment is hard, you know, but that, I think could be addressed and, you know, by a…Site assessment, you know, it’s, like, guess what, you’ve been here for… you’ve been to that site for three months already and in those three months you’ve only done one person. Why do you keep going? Various BRGS program, 3-5 yrs in HIV prevention • Incentive is a major, major, major piece for retention and to get people into program. Once they get in then it’s almost like, it’s come from within, but you need that to get people in. WSR program, 10+ yrs in HIV prevention

47. Maintenance & Evolution • Trainings on Adaptation

48. Maintenance & Evolution • Ongoing Trainings

49. Maintenance & Evolution • Trainings on the Big Picture • …educate staff about the need of… about the history of the development of the DEBIs [CDC EBIs] themselves. I think staff should… we’ve tried to make them aware, but I think going through a formal training might reinforce them of the need to appropriately evaluate programs and the need to meet standards, industry standards because, I think as it is now, there is sometimes a reluctance, “Oh, we’re being forced to do this,” and it hasn’t really been explained well why we’re doing this. Of course, we’ve tried to explain that, it would be nice to hear it from just one person or two, and of course, just having a training whose goal it is to just provide us an orientation of how the program really ought to be implemented with fidelity. MSM & MSMW program, 10+ yrs in HIV Prevention

50. Maintenance & Evolution • Sharing Lessons Learned • I think bringing together groups that are doing the same DEBIs would be beneficial, if for no other reason that we can all just, kinda, hold each other’s hands and woe about our challenges, that I think would be very helpful. MSM & MSMW, 6 yrs in HIV prevention • And then maybe like, you know, how you have your SPA [Service Planning Area] meetings, your service provider network meetings, to sort of have dialogue amongst people who are doing certain, like maybe once a month, people who are funded to do [an EBI], to have like a [EBI] meeting, or people who are like, people who are funded to do Mpowerment, to have an empowered meeting, so that way people could exchange ideas… Transgender program, 5 yrs in HIV prevention